Health reform needs a healthy respect for civil discourse

I recently took part in a “civil discourse,” an unusual occurrence in this era of media pundit-orchestrated shouting matches.

Unlike a debate with winners and losers, a civil discourse begins with the premise that, when there are different points of view on a topic, it is better to understand those with whom we disagree than to turn off the sound.

By listening and asking probing questions, we come to understand how such a smart person could possibly disagree with us.

Set in an architectural masterpiece – Frank Lloyd Wright’s Beth Sholom synagogue in Elkins Park, Pa. — this conversation on “The Role of Government in Health Care” was moderated by well-respected public television commentator Chris Satullo.

No surprise to anyone who knows me, I represented the liberal perspective — i.e., supportive of the Affordable Care Act (ACA) and convinced that its goals are achievable — and Stuart M. Butler, PhD, of the Center for Policy Innovation at the venerable Heritage Foundation in Washington represented the conservative viewpoint.

Although the topic is emotionally charged and politically polarizing, the most striking thing was how many things we agreed on!

Irrespective of our political persuasions, we agreed that healthcare should be affordable, adequate, and equitable.

My conservative counterpart and I also agreed that the healthcare system needs treatment for multiple “diagnoses” – waste (e.g., overtreatment, failure to coordinate care, complex billing processes), misaligned incentives, and an appalling lack of transparency.

Perhaps the most compelling point of agreement was around helping people make more rational decisions around end-of-life care.

The laser-like focus of our disagreement was how the healthcare system should be organized to achieve our mutual objectives.

Dr. Butler views entitlements — Medicare and Medicaid — and other aspects of government involvement as the root of the problem and looks to the marketplace for solutions (e.g., individual government-issued vouchers for healthcare purchases).

The theory is that empowered patients and households with more skin in the game will choose more responsibly and seek value in the dollars they spend on healthcare.

The difficulties are those of getting the market to be adequately transparently organized and transparent, and of helping patients navigate such a system through good information, and well trained and compensated intermediaries, for example.

In my view, the business of healthcare is what has run amok — only the government has the clout to compel the healthcare industry to give patients more accessible, equitable, high quality, transparent care.

Although we still have a long way to go in reducing waste and addressing a medical error rate that, in any other industry, would not be tolerated, positive change is happening as a direct result of the payment reforms (e.g., bundled payments) and new models of care (e.g., medical homes) that are integral to the ACA.

The difficulty I see with my position is that the government makes assumptions and acts on them without benefit of evidence.

So, what did I take away from this “respectful disagreement”?

My views haven’t changed – nor, I imagine, were the views of the over 500 people who attended the program – but that was never the intent.

I did come away with an understanding of how much common ground Dr. Butler and I shared on this hot topic and a healthy respect for civil discourse.

David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University and blogs at Nash on Health Policy and Focus on Health Policy.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    “The difficulty I see with my position is that the government makes assumptions and acts on them without benefit of evidence.”

    Particularly since there is ample evidence on what governments need to do in order to be successful at making health care “affordable, adequate, and equitable”, and existing evidence flies in the face of many current and historical U.S. government assumptions, starting with the segregation of the poor in a different health care financing system, and ending with the brand new unwavering support for transitioning all of health care to the control of corporations.

    • ninguem

      Is there a place on Earth where the poor are not “segregated” in healthcare, or anything else for that matter?

      Instead of legislating against the bottom tier, you legislate to try to make that bottom tier something you would accept for yourself or your mother.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Exactly….

      • Guest

        So what we will see (and I have NO doubt about this) is a lower quality healthcare for all that will be just as, if not more expensive with limited accessibility.

        Great.

  • ninguem

    “Irrespective of our political persuasions, we agreed that healthcare should be affordable, adequate, and equitable.”

    As an ideal, that’s fine. Something to aspire to.

    In reality, it’s not going to happen; it’s never happened anywhere on Earth.

    Problem we’re seeing, is trying to mandate that equality, which is like writing a law making the tides illegal.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Very true. However, “affordable, adequate, and equitable” are not binary
      yes/no concepts, and the question is how we advance our aspirations to
      get closer and closer to the ideal state, which most likely will never
      be achieved (at least in our lifetime).

      I agree that mandating
      equality is a childish strategy, but I don’t think that this is what we
      are actually doing. We are mandating the appearance of equality by
      saying that if you have a rotten, shriveled orange, you are equal to the
      person that has a shiny, juicy apple, because we all have fruit….

      • MM

        But the problem with government wealth distribution programs (which is what taking money from those who have earned it and using it to pay for “free” healthcare for those who haven’t is) is that things inevitably settle out closer to the lowest rather than the highest common denominator.

        Instead of those who /haven’t/ paid for fruit getting stuck with a rotten shriveled orange and those who /have/ paid for fruit getting a shiny juicy apple, everyone – regardless of how hard they work or how much they pay – will get stuck with one of those punnets of strawberries where all the ones on the top look lovely and fresh but all the ones underneath are squashed and starting to grow fur.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          First I would say that the “aspiration” should be that everybody gets a shiny, juicy apple. This however is not possible as long as we have a critical number of people who for one reason or another cannot contribute to the buying apples effort. The first step towards this aspirational goal should probably concentrate on solving this problem and therefore drastically reducing the need for wealth redistribution. Of course, this will irk some of the largest wealth holders, whose wealth is not proportional to their own hard work, but more to their ability to exploit other people’s hard work. Sadly, we are making no progress in this area, and quite the opposite is true.

          Second, I would point out that the outcomes of hard work are highly dependent on the locale. The same hard work and extensive education in say, Rwanda, will not produce the same apple buying power as it does in say, the U.S. So hard workers must internalize some of the costs of maintaining an environment conducive to high valuation of hard work.

          Third, wealth redistribution is only one type of redistribution required. In the event of a major threat, we, as a nation or society, reserve the right to demand redistribution of life itself from select groups of people who are not too young, not too old, and preferably have a Y chromosome, to everybody else that is not currently biologically endowed with the same. If that is acceptable in order to maintain a fertile environment for hard work, then financial redistribution in the amount needed for medical care, pales by comparison.

      • ninguem

        Mandate “equality” or “the appearance of equality”, what difference does it make? They can’t mandate “equality” in that it would be impossible. Healthcare is NEVER “equal”.

        Look at the Web site of a UK physician, they may have NHS hours and private hours. See NHS patients in one setting, private patients in another.

        With Medicare, we’re 100% in or 100% out. That was not the intention of Medicare in the first place, in fact, the original enabling legislation allowed docs to accept Medicare as payment in full, or in part.

        The AMA’s objection at the time, was that eventually, Medicare would be forced on physicians as payment in full, then the government could lower it as much as they wanted. The AMA was pilloried as troglodytes for their objection, but in fact, that’s what has come to pass.

        Back in the 1980′s or early 1990′s, a group of physicians actually tried to bring litigation over that issue; that is, see some Medicare patients with Medicare as payment in full, see others on a “balance-bill” basis. As I recall the case was thrown out of court.

        As far as I know, the issue is not really settled.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I don’t think equity and equality are the same, and I don’t think that Medicare and Medicaid prohibiting you from doing what the NHS docs do is right either. As long as public funding pays for equitable care, people should be able to buy and sell whatever they want on top of it. I grew up in a system like that and almost never used the universal insurance card, although it was nice to have just in case something really horrible happened. Most people I know used it all the time and were very happy with it, because we saw the same doctors, but I was paying for the plush carpeting and soft classical music, and they got linoleum and overhead alert systems instead. Same quality of actual care though.

          • ninguem

            That system would be Israel, I assume? I don’t know you, I’m guessing from your name.

            I don’t know how Israel sorts this out, probably as well or badly as everywhere else.

            They have a parallel public and private system? I don’t know.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            It is Israel. They have universal health care, financed by taxes and administered through a handful of insurers. The government insurance is very comprehensive, but people by supplemental insurance now for all sorts of upscale stuff (they didn’t use to when I was living there). Doctors are mostly employed by hospitals and insurers, but they have the same arrangement as in the UK, so they see patients privately, if they want to. Most hospitals are public or owned by the insurers, and a few are private. The best ones for serious stuff are the academic ones, of course. The beauty there is that whether you are the prime minister or a homeless person, you go to the same hospital and are treated by the same exact doctors (the amenities are of course different… :-))

          • ninguem

            Are you?

            Or is the Prime Minister treated by Doctor Goldstein, and the homeless person is being treated by Doctor Goldstein’s resident or registrar, or whatever they might call it in Israel?

            I says that, having had UK registrars complain about that very thing in their country. Their consultant is nowhere to be found, as they are in a private hospital doing private work, and the trainee is supervised, on paper, by that same consultant.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            It’s Dr. Goldstein :-) for both…. really…. I don’t know what a registrar is, but in academic centers you’ll get residents involved in care. Perhaps the Prime Minister is spared contact with residents. I don’t know. But I do know that Dr. Goldstein will be there for both. It is a semi-socialist country.. remember? People do honestly believe in that stuff…. and the best part is that when the docs don’t like something, they go on strike…. doesn’t take very long to resolve issues…. :-)

  • EE Smith

    “only the government has the clout to compel the healthcare industry to
    give patients more accessible, equitable, high quality, transparent care”

    What was so bad about the healthcare and health insurance system before 1965, before the government stepped in to create Medicare and Medicaid? Maybe government isn’t the answer, but the source of the problem.

  • Dave

    Another point we can probably all agree upon is that the path we take will require reconsideration and adjustments in the future. Healthcare is too complex and the issues too deeply rooted for one swipe of legislation to fix, and only the most naive on either side would claim their policies would be completely free of unforeseen consequences. Going forward, civil discourse is the only way to confront the issues that arise and effectively plot our way through them.